Psychiatric Nursing.drjma

DR. JAMES M. ALO, RN, MAN, MAP, PhD

PSYCHIATRIC NSG

Models of Mental HealthMental health:• state of emotional, psychological & social wellness (effective coping,

(+) self-concept, emotionally stable).

Mental disorder:

•Defined generally as health conditions marked by alterations inthinking, mood or behavior taht cause distress, impair ability tofunction, or both (USDHHS, 1999).

Mental illness• Is considered a clinially significant behavioral or psychological

syndrome experienced by a person and marked by distress, disability,or loss of freedom (APA, 200).

Biomedical model

7/26/2011James M. Alo, RN, MAN, MAP, PHD.

What you see is just the tip,what lies beneath is the truth about it.

7/26/2011James M. Alo, RN,MAN,MAP,PHD.

Factors influencing mental health� INDIVIDUAL – person’s biologic make-up, autonomy and

independence, self-esteem, capacity for growth, vitality, abilityto find meaning in life, emotional resilience, sense of belonging,reality orientation and coping or stress management abilities.

� INTERPERSONAL – or relationship, may include effectivecommunication, ability to help others, intimacy, and a balance ofseparateness and connectedness.

� SOCIAL / CULTURAL or ENVIRONMENTAL - include asense of community, access to adequate resources, intolerance ofviolence, support of diversity among people, mastery of theenvironment, and a positive, yet realistic, view of one’s world.

CONCEPT OF POSITIVE MENTAL HEALTH� 1.Attitudes toward the individual SELF� Involves aspect related to :

a. Self-acceptance - regard for oneself with arealistic concept of strengths & weaknesses.b. Self-awareness - is noticing how the self feels,thinks, behaves and senses at any given time.c. Self-concept - encompasses all what a personperceives, knows and holds to be true abouthis/her identity.

Aspects of self-concept

BODY IMAGE

PERSONALIDENTITY

SELF-ESTEEM

ROLEPERFORMANCE

2. Growth, Development, Self-Actualization

Is what a person does with his abilities and potentialities over a period oftime.� Future goals and investments in living are involved

3. Integrative Capacity� Core Concept : the relatedness of all processes & attributes in an

individual which influence unified or synchronized personalfunction.

� Concerns the ability of the individual to tolerate anxiety andfrustration during resistance to stress.

� Psychoanalysts view : a balance of psychic forces.(id,ego,superego)

4. Autonomous Behavior

� individual’s ability to personally regulate hisdecision-making & actions so that these functionsrelatively independent of physical and socialinfluences.�ability to refuse to conform when to do is a social

expectation that conflicts with one’s value system.

5. Perception of Reality� How the individual views and reacts toward the world around him .- ability to perceive reality while being free of needs which could

distort individual perceptions.

6. Mastery of One’s Environment� ability to ADAPT, ADJUST and BEHAVE appropriately in situations

and in accordance with culturally approved standards so thatsatisfactions are achieved in love, work, play and interpersonalrelations.

- ability to solve problems with expression of appropriate feelingtones and direct attack.

HISTORICAL BACKGROUND� ANCIENT TIMES

…people believed that any sickness indicated displeasure ofthe Gods and in fact was punishment for sins and wrongdoings.… mental disorders wereviewed as either beingdivine or demonicdepending on theirbehavior.

Renaissance (1300-1600)� People with mental illness were distinguished from criminals� Those considered harmless were allowed to wander and live in the

rural areas� Those “dangerous lunatics” were thrown in prison, chained, and

starved

1547Hospital of St. Mary of Bethlehem, first hospital for the

insane was built

1775visitors at the institution paid to view and ridicule the

inmates like animals

Mentally ill patients were considered evil orpossessed and were burned at the stake

Period of enlightenment� 1790s

– Phillippe Pinel and

Willian Tukes formulated

the concept of asylum

as a safe refuge or haven

offering protection to

mentally-ill people

� Dorothea Dix

(1802-1887)

– began a crusade

in the USA to reform

treatment of the

mentally ill.

She opened 32 state

hospitals that offered

asylum.

Period of scientific discovery� Period of scientific study and treatment of mental illness began

with:� Sigmund Freud (1856-1939) – studied the mind, its disorders

and treatment� Emil Kraepelin (1856-1926) – classified mental disorders

according to their symptoms� Eugene Bleuler (1857-1939) – coined the term “schizophrenia”

LINDA RICHARDSfirst American psychiatric nurse.She believed that, the mentally sickshould be at least as well cared foras the physically sick

The first training of nursesto work with persons with

mental illness was in 1882at McLean Hospital inWaverly,Mass.

The first psychiatric nursingbook – Nursing MentalDiseases by Harriet Bailey waspublished in 1920

In 1913 John Hopkins was thefirst school of nursing toinclude a course in psychiatricnursing in its curriculum

Two early nursing theoristsshaped psychiatric nursingpractice: Hildegard Peplau andJune Mellow.

1845first authentic book on psychiatric disorder wasreleased

1950sbirth of psychotropic drugs; first to be createdwere:

Thorazine – antipsychotic drugLithium – antimanic drug

NEUROSCIENCE: Biology & behavior

NeuronDendrites Receive impulses

Axon •Semd impulses away

Neuromuscularjunction(NMJ)

•Connects nerve to muscles

Glialcell/neuroglia

•Are supporting cells, they include:

üOlegodendrocytes – produce myelin in the CNSüMicroglia – phagocytes/scavengers of the CNSüAstrocytes – structural supporting cells

Myelin •Insulates axons & allow faster impulse conduction

üSchwann cell - #schwann cell myelinates #axon in the PNSüOlegodendrocyte – myelinates several axons in the CNS

NeurotransmittersAcetylcholine (Ach)• Is both excitatory (depolarizes membranes) & inhibitory

(hyperpolarizes membranes); is used by all motorneurons, the brain, & both sympathetic, & parasympateticsystems.

• Reduced in alzheimer’s dementia & myastenia gravis.

Biogenic amines• Tyrosine" Dopamine "Norepinephrine "Epinephrine• Tryptophan "serotonin; "histidine "histamine• Metabolized by Monoamine Oxidase (MAO) & Cathecol-

O- Methyl Transferase (COMT)

Dopamine §Excitatory, seen in midbrain for control ofcomplex movement, motivation, cognition& emotion.§$ In Parkinson’s d’s & depression§#in schizophrenia, mania, Tourette’ssyndrome

Norepinephrine(Noradrenaline)

§Excitatory, in postganglionic sympathetic neurons(figt or flight) & in the brain (attention, memory)

Epinephrine(adrenalin)

§In anxiety disorders§$in depression, low impulse control

Serotonin §Inhibitory, in brainstem, linked to impulse control§#in depression, low impulsecontrol

Histamines §Modulator, seen in hypothalamus,#in allergies

Amino acidshaminobutyric acid(GABA)

•Primary inhibitory transmitter in CNS•$in anxiety, #by benzodiazepines &barbiturates

Glutamate •Primary excitatory transmitter in CNS•#in Huntingtons chorea, alzheimers

Glycine •Inhibitory in spinal interneurons

Nitric Oxide §Inhibitory, gas form, affects central & entericnervou system§Relaxes vascular smooth muscle causingvasodilation.

Neuromodulators

Neuropeptides

• Enkephalins,endorphins, substance P, somatostatin,VIP, CCK, Neurotensin, ACTH, angiotensin

Alter sensitivity of synaptic membranes toneurotransmitters

• (my enhance, prolong,, or inhibit transmittereffects.

Central Nervous System

Cerebral Cortex� Divided into 2

hemispheres:� Left: controls right side of

the body as well as logicalreasoning & analysis fxns;(reading, writing, &math).

� Right: controls left side ofthe body as well as;creative thinking, intuition,& artistic abilities.

Further divided into 4 lobesFunction Impairment

Frontal lobes

Motor cortex Found in precentral gyrusFor voluntary motor activity

Mono or hemiplegia dependingon the extent

Premotor cortex Planning of movement

Contralateral head & eye turning

Bowel & bladder inhibition

Apraxis – loss of learnedmovementParalysis of head & eye toopposite sideIncontinence

Broca’s area Expression, motor for speech Expressive aphasia – can’t speakright

Prefrontal area Personality & emotion, judgment& inhibition, concentration &elaboration of thought

Personality changes: antisocialbehavior, loss ofinhibitions/impulsive, poorconcentration.

PSCHOANALYTIC THEORYSIGMUND FREUD(1856-1939)

Father of …PsychoanalysisModern Psychiatry

Psychoanalytic theory� Supports the notion that all human behavior is caused and can

be explained•• Supports the notion that all human behavior isSupports the notion that all human behavior iscaused and can be explainedcaused and can be explained

•• He believed that repressed sexual impulses andHe believed that repressed sexual impulses anddesires motivated much human behaviordesires motivated much human behavior

Theory of Psychosexual Development bySigmund Freud

� Oral Phase- 1 yr. old� Greatest need- security� Greatest fear- if anger anxiety� Narcissistic- pleasure seeking

is through eating & sucking;primary narcism( self-love)

� Mouth- erogenous zone,area of satisfaction

� Insecurity in parting withbreast or bottle may cause fixation

� Tension is relieve by sucking & swallowing� Sucking need is independent of hunger satisfaction.

� Anal phase -Primary source of pleasure iselimination/retention� This is the critical period

for toilet training� Anus- site of tension

& sexual gratification� Greatest need: power� first experience with

discipline & authority� retention & expulsion (forcing out are experienced as pleasurable

especially because these functions come under the child-control.)Child uses his new skill to please or annoy parenting adult.

Theories of Personality� Freudian Concept

� Sigmund Freud – the father of psychoanalysis stressed that earlychildhood experiences is important in the development ofpersonality.

Three Components of Personality

ID� part of personality in which we are born� it is primitive, it demands immediate satisfaction� functions according to pleasure principle� unconscious part of the person which serve as the reservoir of primitive

& biologic drives & urges� reflects basic or innate desires such as pleasure seeking behavior,

aggression &sexual impulses.

� Totally self-centered� Developed during infancy� Seeks instant gratification� Impulsive, unthinking behavior� No regard for rules or social

convention

“too much id”“too much id”7/26/2011James M. Alo, RN,MAN,MAP,PHD.

Ego� the self or the I� known as the integrator of personality� Part of the mind which acts with the outside world, partly conscious &

partly unconscious� operates on reality- principle. If it develops it supercedes the pleasure

principles in guiding behavior� this is developed during the toddler period� conscious self. the “ I ” that deals with reality� part of personality that’s evident to the environment� Balancing or mediating force between the id and the superego.� Represents mature and adaptive behavior that allows a person to

function successfully in the world.� ANXIETY results from ego’s attempt to balance the impulsive instincts

of the id with the stringent rules of the supergo.

Superego� the conscience� the automotive or parental directions which incorporated in the

personality as the CENSORING FORCE.� this is developed during the preschool age� Strict Superego- leads to rigid, compulsive, unhappy person� Weak/Defensive Superego – leads to antisocial behavior, hostility� reflects moral & ethical concepts, values, parental and social

expectations� controls, inhibits & regulates impulses & instincts whose

uncontrolled expression would endanger the emotional well-beingindividual & the stability of the society.

� Direct opposition to the id.

MENTAL DISORDER

FREUD’SPsychoanalytic/psychodynamic model

Personality functions @ 3 levels ofawareness:

= Neurotic benhavior is a result of childhoodtrauma or failure to complete tasks or needs ofpsychosexual development:

Narcissistic defenses

Anxiety/Neurotic defenses

Immature defenses

Mature defenses

Examples of psychiatruc disorders &defenses used:

ERIKSON’S Psychosocial developmentmodel

?Psychosocial growth occurs in a series of 8 developmental stages w/each stage involvinf a task w/ (+) & (-) experiences.?Completion of said task allows one to achieve life virtues.

PIAGET’s Cognitive Developmental Model= Focus of child dev’t is on genetics, envi., moral, &intellectual dev’t.

KOHLBERG’s Moral Developmental Model= Expanded Piaget’s Moral Developmental Model

MASLOW’s Heirarchy of Needs Model� Basic human needs are elements, shared by all people that are

necessary for human survival & health

� Certain needs are more basic than others .i.e. Some needs mustbe met before others.

Self-actualization

Self-esteem

Love & Belonging

Safety & security: Physical &psychological

Physiologic: O2, fluids, food, temp.,elimination, shelter, sex

PAVLOV’s & SKINNER’s Behavioral Model� Behavior is observable, predictable & controllable.

� It can be changed by a system of rewards & punishments.

PAVLOV’s Classical Conditioning

SKiNNER’s Operant Conditioning

Random intermittent reinforcement (reward for desired behavioronce in a while) is the slower but more permenent of increasing

desired behavior.

Continuous (+) reinforcement (reward each time behvior occurs) isthe fastest way to #a behaviors recurrence but be havior is short-

lived after after the rewards have ceased.

Behavior is learned from repeatedly reinfirced experiences

(+) reinforcement /reward � abehaviors recurrence

(-) reinforcement/ punishment $ abehaviors recurrence

SYSTEMATIC DESENSITIZATION

EXTINGUISHED

Untill fearresponses is

EVENTUALLY

Gradual exposureto feared stimuluswhile clients are

relaxed

Application ofconditioning as

clients are helpedto overcome their

PHOBIAS

SELYE’s Stress Adaptation ModelPhysiological response to stress correlated to anxiety level

GENERAL ADAPTATION SYNDROME (GAS)

Stage 1.Alarm Reaction (fight/flight response)• Physical; #Epinephrine & Nor-epinephgrine= sympathetis response• Psychosocial:Alert. #anxiety (1+, 2+), inefficient problem-solving

Stage 2. Ressistance (Optimal adaptation to nstress)• Physical: adrenal cortex & it’s hormones readjust, weight normalizes• Psychosocial:#Coping mechanisms, defense oriented behavior

Stage 3. EXHAUSTION (Inability to cope, depleted resources)• Physical: $immune response, hormones, weight"organ failure• Psychosocial: exaggerated behavior, disorganized thought & personality, delusions,

hallucinations, stupor/violence.7/26/2011James M. Alo, RN,MAN,MAP,PHD.

PSYCHIATRIC ASSESSMENT� PSYCHIATRIC HISTORY

MENTAL STATUS EXAMI. GENERAL DESCRIPTION

II. EMOTIONS

III. SPEECH – described terms of quantity, rate ofproduction & quality: ex. Talkative, non-spontaneous,hesitant, slurred

IV. PERCEPTUAL SIDTURBANCES – process by whichphysical stimuli are brought to mental awareness

V. THOUGHTA. Process/ form of thought – way a person puts togetherideas & assoc., form in w/c a person thinks.

B. CONTENT OF THOUGHT – What person is actuallythinking about: beliefs, ideas, obsessions, preoccupations.

VI. CONSCIOUSNESS (state of awarenes), SENSORIUM(awareness of special senses), & COGNITION (awareness ofthought).

PSYCHIATRIC DIAGNOSIS

� NANDA Accepted Nursing Diagnosis

INTERVENTION: TherapiesTHERAPEUTIC NURSE-CLIENT REL. (Peplau)� Therapeutic use of self focus on both client-nurse needs� Has 4 PHASES:

TECHNIQUES OF THERAPEUTIC COMMUNICATION

PYSCHOPHARMACOLOGY

NURSING INTERVENTION

� STIMULANT DRUGS

CLASSIFICATION OF MENTALDISORDERSA. Disorders usually evident in infancy, childhood & adolescence

1. MR2. PDD3. Disruptive behavior disorders4. Anxiety disorders of childhood & adolescence5. Eating disorders6. Gender identity disorders7. Tic disorders8. Elimination d’rs9. Speech dr’s

B. Organic mental syndromes disorders1. Organic mental syndromes

a. Deliriumb. Dementia

2. OMD (dementias arising in the sensium & presensium)

a. Primary degenerative dementia (senile onset)b. Primary degnerative demntia (presenile onset)

3. Psychoactive substance use dr’s

C. Psychoactice substance use dr'

ANXIETY DISORDERS

LEVELS OF ANXIETY

ANXIETY DISORDERS

NURSING INTERVENTIONS TO $ANXIETY

SOMATOFORM DISORDERS

DISSOCIATIVE DISORDERS

FACTITIOUS DISORDERS

ACHIZOPHRENIAS & OTHER PSYCHOTICDISORDERS

OTHER PSYCHOTIC DISORDERS

NURSING INTERVENTIONS FORPSYCHOTIC DISORDERS

Mood Disorders

Depressive DisorderA. Major Depressive D’r

Intervention for Depressed Px

Bipolar Disorders

INTERVENTION FOR MANIC PX

COGNITIVE DISORDERS

Types of Dementia

NURSING INTERVENTION FOR COGNITIVE D’R

PERSONALITY DISORDERS

DEVELOPMENTAL DISORDER

Classification

Elimination Disorders

Tic Disorders

SUBSTANCE RELATED DISORDERS

Alcohol Abuse

� Psychoactive Drug Abuse

� COMMONLY ABUSE DRUGS

EATING DISORDERS

SEXUAL DISORDERS

DEATH & GRIEVING

ONCOLOGY NURSING� NEOPLASTIC DISEASES

� A. Characteristics1. Etiology

a) Healthy cells transformed into malignant cells upon exposure tocertain etiological agents: viruses, chemical & physical agents.

b) Failure of immune response

2. Pathophysiologya) Rapid cell divisionb) Malignant cells metastasize

1. Extending directly into adjacent tissue2. Permeating along lympathic vessels3. Traveling through lymph system to nodes4. Entering blood circulation5. Diffusing into body cavity

� 3. Classification of tumorsa. Accdg to type of tissue from which they evolve

1) Carcinomas begin in epithelial tissue (ex: skin, GI tract lining, lung,breast, uterus)

2) Sarcomas begin in non-epithelial tissue(ex: bone, muscle, fat, lymphsystem)

b. Type of cell in which they arise; cell types affect appearance,rate of growth & degree of malignancy.

� 4. Staginga. Describes extent of tumorü T= primary tumorü N= regional nodesü M= metastasis

b. Describes extent of malignancy to which malignancy has # in sizeü To= no evidence of primary tumorü Ts= carcinoma in situü T1,T2,T3,T4= progressive #in tumor, size & involvementü Tx= tumor cannot be assessed

c. Involvement of regional nodesü No= regional lymph nodes not abnormalü N1-4= #degree of abnormal size

d. Metastatic dev.ü Mo= no evident of distant metastasisü M1-M3= #degree of metastasis

� B. Manifestations > Malignant d’s (ACS 7 warning signs)1. Change in bowel/bladder movement2. Sore that does not heal3. Unusual bleeding /discharge4. Thickening/lumps in breast/ elsewhere5. Indigestion/difficulty of swallowing6. Obvious change in wart/mole7. Nagging cough/hoarseness

� C. Cancer therapy1. Objective: to cure

1. Prevent further metastasis2. Relieve manifestations3. Maintain high quality life

2. Surgery1. Radical2. Prophylactic3. palliative

3. Chemotherapy1. Drugs interfere w/ cell division

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